The madness of a cure for insanity

Anthony Daniels reviews Madhouse by Andrew Scull.

Anthony Daniels

12:01AM BST 08 May 2005

The history of medicine is replete with theories and practices that seem absurd and bizarre to subsequent generations. How could any sensible person have entertained ideas or done things that were so obviously wrong-headed and even cruel? No doubt medicine is not the only profession or discipline of which this question can be asked, but since all of us end up one day or other having medical treatment, it is particularly disturbing when asked of medicine. How do we know that the present generation of doctors is not in the grip of some collective delusion, as previous generations of doctors so obviously were?

Andrew Scull, a social historian of psychiatry, has uncovered one such delusion from the first quarter of the 20th century, which had terrible consequences for untold numbers of patients. Dr Henry Cotton was the medical director of the Trenton State Hospital, a large lunatic asylum in New Jersey, who convinced himself that madness was caused by focal sepsis, that is to say subclinical infection of the teeth, tonsils, sinuses and colon. Thus the answer, he believed, was to remove the teeth and tonsils, wash out the sinuses and, most drastic of all, cut out the colon.

The latter operation, performed in the asylum by Cotton himself - although he had no formal training in surgery - had a death rate of up to 33 per cent, but this did not deter him from continuing his "pioneering work". He claimed a very high success rate for his operations, many of which were forced upon unwilling patients: 85 per cent of his lunatics were cured by them, he said. A skilful self-promoter and publicist, he was widely believed and lionised, especially in Britain.

His claims were disputed, particularly by the investigations of Dr Phyllis Greenacre, who proved that the chief clinical effect of his operations was the death of his patients. But Cotton was protected by his former teacher and mentor at Johns Hopkins medical school, Professor Adolf Meyer.

Meyer was a Swiss psychiatrist, an intimidating pedant rather than a real scientist, who was the undisputed doyen of American psychiatry for many decades. He wanted above all to avert a scandal that would damage the standing and power of the profession, and was prepared to countenance the continued mutilation of patients by Cotton to do so. He suppressed Dr Greenacre's work.

But how did so flimsy and, to our eyes, foolish a theory of the cause of madness come to be accepted in the first place? It did not look so absurd then as it does now: the germ theory of disease, which elucidated so many mysteries, was comparatively new, the syphilitic cause of general paralysis (from which up to a fifth of the asylum population suffered) had just been discovered, and hidden infections do indeed often result in acute confusion in the elderly, including hallucinations and delusions. It was, therefore, a comparatively short step to hypothesise an infective cause for all madness.

While Dr Cotton was an avid self-promoter, whose zeal to discover something medically important was probably greater than his ability to do so, he was no mere self-server: he believed in his own theory to such an extent that, as a prophylactic method, he extracted the teeth of two of his sons and even subjected one of them to a colectomy (both committed suicide as adults). Later, he had his own teeth extracted, believing focal sepsis to be the cause of his angina.

He probably persuaded himself that, without treatment, the prospects of his patients were so wretched that an operative death rate of 33 per cent was justified if it offered some patients the hope of cure. Moreover, he was in blood stepp'd in so far that returning were as tedious as go o'er. But his theory more or less died with him, in 1933. Meyer wrote a laudatory obituary of Dr Cotton, though he must have known by then that Dr Cotton was responsible for hundreds of deaths and untold misery besides.

Prof Scull tells the story brilliantly. Although this is an academic study, 20 years in the writing, it reads almost as excitingly as a good thriller, but it has a more serious purpose than merely to entertain. Prof Scull believes that the case of Dr Cotton is emblematic of the inevitable abuse of professional power once it is handed over to so-called experts, and he cites other examples of horrific treatments developed by 20th-century psychiatrists to support his contention: frontal leucotomy, Metrazol-induced convulsion therapy and insulin coma therapy among them.

If he somewhat over-eggs the pudding, failing to recognise just how desperate the situation of an untreated psychotic can be, his excellent book nevertheless stands as a warning to doctors to remember that not everything done in the name of therapeutics is justified. However, I wouldn't like to swear that another Dr Cotton is completely impossible.